Risk new openness rule will lead to greater silence

New rules ordering NHS organisations to tell patients when their safety or care has been put at risk could conversely lead to fewer incidents being reported by nurses and frontline staff, it has emerged.

The Department of Health announced last week that from April 2013 NHS providers will be contractually required to tell patients when mistakes happen, under what is described as a “duty of candour”.

Health minister Dr Dan Poulter said the change would “boost transparency and openness”.

However, the government’s own impact assessment of the rule change warned there was a “theoretical risk” that it would in fact lead to staff speaking up less than they do now.

It stated: “Admitting to making a mistake or being involved in an error or incident is difficult at the best of times. It is much more difficult when admitting involvement in an incident to the very person who has been harmed or someone who cares about the person who has been harmed.”

Staff “may be even more likely [than at present] to decide the risk of the consequences to them personally, outweigh the positive benefits of reporting the incident”, the risk assessment warned.

It added: “Put simply, the more punishments that are associated with an error or incident, the more likely a person is not to report it at all – therefore not only does the patient not get told, the incident may not even be reported.

“This could have knock-on effects on learning, improvement and ultimately the safety of healthcare.”

The DH has said it was difficult to quantify the risk and stressed the duty rested on the organisation, rather than the clinician, and consequences would be for the trust and chief executives.

Chris Cox, head of legal services at the Royal College of Nursing, said: “The real issue here is around the culture of the organisation.

“If you have a culture of no blame and not picking on the individual, the people will volunteer information. But if you have a culture of singling out the individual when things go wrong, then you will push these problems even more underground.”

He added: “It is critically important that nurses speak up, it is a requirement of their professional code. They must have the courage to speak up when things are going wrong.”

bullying and picking on one person is what many managers do, they rarely accept that a mistake usually has mitigating factors and ultimately involves more than one person. they like to make an example of one person, don't take any responsibility for being part of a chain of events and prefer to discipline someone just to be seen to be doing the right thing.

'It added: “Put simply, the more punishments that are associated with an error or incident, the more likely a person is not to report it at all – therefore not only does the patient not get told, the incident may not even be reported.

“This could have knock-on effects on learning, improvement and ultimately the safety of healthcare.”'

This is the long-standing problem of separating 'honest mistakes' from 'culpable negligence'.

Somehow, it has to be worked out how the 'I keep hitting myself on the thumb with the hammer - I'm not trying to do this, I'm not blaming myself but I have got to stop doing it !' mindset can be incorporated into 'organisational mistakes'.

It is a huge problem: unless people are open, it escalates distrust and confrontation, but before staff in particular are willing to be open, they need to be confident that they will not be blamed for what I would call 'reasonable or unavoidable mistakes/problems'.

'tinkerbell | 12-Dec-2012 10:14 am

what you mean they haven't really thought it through?'

It isn't, as I hope I've explained above, a case of not thinking it through here - it is just a hugely complex issue !

Many managers investigating cases do not look for the root cause analysis. If they did learn how to do it properly, they would be less likely to shoot the messenger or look for easy targets to blame. It is vital that people have a knowledge of how organisations work and how problems develop. It is more difficult to work out the difference between negligence and culpability and the organisational shortcomings that are likely to lead to mistakes

No apology necessary - it is clear that your 'so they hadn't thought it through' comment was out of frustration, not misunderstanding: but you do always have to consider whether 'impossible guidance' stems from a lack of 'thinking about it deeply' as opposed to 'knowing back-covering'.

I get seriously irritated, when people don't analyse things to a conclusion, and don't publish what I would call 'sensible and balanced guidance'.

And this 'telling people to be honest will create honest cultures of itself' isn't 'thought through' - and asking nurses to 'speak up' when so many then get bullied/victimised is 'unrealistic': it should not require the bravery of a Kamikaze to raise concerns about problems ! So the system has to be designed to facilitate that, even if a 'bad management' is trying to hamper the process. And so far, the suggestions/mechanisms I've seen stop some distance short of that facilitation.